Cardiologists' concerns: Abnormal heart rhythm, blood thinners, and statins

A survey of local cardiologists finds that they want patients to be more aware of the perils of an abnormal heart rhythm as well as the value of newer blood thinners and cholesterol-lowering statins.

The survey of 475 heart specialists at dozens of hospitals and private practices was conducted this month by the Cardiovascular Institute of Philadelphia, an independent nonprofit dedicated to improving heart health in the Delaware Valley through educational programs.

More than 70 physicians responded to the survey, which asked them to pick three important cardiology issues or developments that they felt patients should know more about. They selected from 16 topics, including insurance challenges, new treatments for varicose veins, energy drinks, and the pluses and minuses of aspirin therapy.

Among the top issues was the "epidemic" of atrial fibrillation, the irregular, often rapid heart rate that can lead to blood clots, heart failure, and stroke.

In the U.S., "a-fib" affects an estimated 2.2 million people, a number likely to grow as the population ages. A-fib is typically treated with a blood thinner to keep dangerous clots from forming.

Many people, however, go undiagnosed until they have a minor or major stroke, in which a clot formed in the heart travels to the brain and blocks a blood vessel.

A-fib "may be asymptomatic or intermittent. Some people feel it, some don't," said Abington cardiologist Bruce Berger, explaining the underdiagnosis. "And I think some people are under the impression that it's common, so it can't be that serious."

Lansdale cardiologist Michael Zakrzewski urges patients not to ignore palpitations, even if the racing heartbeat seems isolated or infrequent.

"If there's any question, we can do an EKG," he said, referring to an electrocardiogram, a quick, painless test that checks for problems with the heart's electrical activity.

A comforting development for a-fib patients is that they now have options for anticoagulation.

Warfarin has been the standard blood thinner for more than 50 years, but its potency can be affected by certain drugs, genetic variations, and vitamin K-laden vegetables, so patients' blood levels have to be carefully monitored and adjusted.

Three new anticoagulants for a-fib - dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis) - have come on the market in the last three years, and just last month, the Food and Drug Administration approved edoxaban (Savaysa). They don't require routine blood-level checks.

"Patients who have difficulty with bleeding and stability on warfarin are good candidates" for a newer anticoagulant, Zakrzewski said.

The downsides: The drugs are expensive. And unlike warfarin, which can be reversed with a shot of vitamin K, the newcomers don't have an antidote if unwanted bleeding occurs.

Another issue of importance for many of the survey participants is statins, a class of at least seven drugs that reduces production of cholesterol, which can clog arteries and contribute to heart disease.

A statin is standard care for preventing a repeat heart attack ("secondary" prevention). It is recommended for patients who are at elevated risk for a heart attack because of factors such as high blood pressure, smoking, diabetes, and family history.

"Statins continue to be the most important drug to decrease cardiovascular risk for both primary and secondary prevention," said Mario Maiese of South Jersey Heart Group.

Still, statins have become controversial, with critics contending they are overprescribed, especially for people without diagnosed blood-vessel disease in whom benefits are not clear cut. Statins also have common side effects, notably muscle pain. One brand, Baycol, was removed from the market in 2001 after being linked to rhabdomyolysis, a potentially fatal breakdown of muscle tissue.

Heather Horton, of Wilmington-based Delaware Cadiovascular Associates, said she takes a more conservative stance on statins for primary prevention, particularly in women, than the 2013 guidelines from the American Heart Association/American College of Cardiology. The groups now urge statins for people with a 10-year heart attack/stroke risk of 7.5 percent instead of the previous 10 percent risk.

"The question is whether the balance has shifted to some inappropriate prescribing," she said. "I'm in my fifties, and my LDL [bad cholesterol] level is high. But I have no other risk factor. I'm not going to take a statin."

For patients who aren't convinced when their family doctor recommends a statin for primary prevention, Horton suggested several strategies: Try to cut cholesterol for six months with diet and exercise. Get a blood test for C-reactive protein, another potential risk factor. Use a government website (http://cvdrisk.nhlbi.nih.gov/) to estimate your 10-year risk for heart disease.

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